The Los Angeles Fire Department, with help from several major medical groups, is upgrading its ability to respond to and treat on scene non-emergency calls, which it believes will make more first responders available for emergencies.
The Advanced Provider Response Response Units (APRUs) pair either a nurse practitioner or physician’s assistant with a LAFD paramedic. The two-person team will respond to calls involving more minor injuries, where a patient can be evaluated, treated, and possibly released at the site of the call. LAFD and medical officials are hoping this could lessen the amount of human traffic brought to urgent care and emergency rooms by ambulance, and in turn shorten the amount of time patients with serious or critical injuries must wait before getting help.
“They are almost like a combination of an ambulance and urgent care on wheels,” said LAFD Medical Director Dr. Marc Eckstein, during a press conference introducing the four new APRU teams held at the LAFD Training Center near Dodger Stadium.
Half of the 14 Los Angeles city fire battalions now have APRU service, Chief Ralph Terrazas said. Three went into service Monday, July 23 — at Fire Station 7 in Van Nuys; Fire Station 58 in West Los Angeles; and Fire Station 4 in downtown Los Angeles. The fourth unit will operate out of Fire Station 84, serving Woodland Hills, as soon as a two-person crew is assigned.
The financing for the physician’s assistants’ salaries comes from Providence Health & Services Southern California, Cedars-Sinai, Kaiser Permanente and Dignity Health — as well as the Los Angeles Fire Department Foundation. The funding is for one year, and will pay the salaries of the physician assistants hired by the fire department,
Providence is funding the two units that will work in the San Fernando Valley.
“[APRUs] can safely and rapidly evaluate low-acuity emergency medical patients, and treat and release on scene, thereby avoiding unnecessary transport by ambulance to an emergency department,” Eckstein said.
“They can also perform medical clearance for patients suffering an acute mental health crisis or public intoxication. Once they perform the clearance, they are allowed under state law —unlike paramedics, who are not allowed — to transport those individuals to free-standing mental health urgent care centers, where the patient can get almost immediate mental health counseling and/or evaluation, while [DUIs] can be transported to a free-standing sobering center located in the skid row area of downtown Los Angeles.
“That can help some of the most vulnerable patients in our society, many of whom are homeless, and frees up [other] ambulances and paramedics to do what they’re really trained to do — take care of life-threatening problems,” he said.
The APRU program is an outgrowth of the response teams first developed in 2016 (using nurse practitioners exclusively with paramedics) as LAFD and medical officials were grappling with how to continue responding and serving the growing number of 9-1-1 calls being made in Los Angeles.
“LAFD is one of the biggest providers of acute, unscheduled care in the city of LA. We see as high a volume as the top four [emergency departments] combined — which is remarkable because people don’t think of us as a medical provider,” said Dr. Steve Stanko, assistant LAFD medical director.
Stanko said the 9-1-1 call center receives “about one million calls per year, which ultimately results in around 420,000 unique emergency medical service incidents/calls for medical help.” Historically, he said, the volume of calls would increase at a rate of 2 percent per year from the 1990s to around 2005. But from 2006 to 2010 the call volume increased to 5.5 percent, then took a dramatic rise to 20 percent from 2012 to 2016.
The increases could be due to more available phone technology or a larger population. But, Eckstein said, both the 9-1-1 call center and area hospitals were being strained.
“We’ve struggled to keep up with that volume,” he said. “In addition, our stakeholders in the health care community and emergency departments have suffered from overcrowding, incredibly long waits for ambulances to off-load patients, and long waits for patients to be admitted. We realized that a significant percentage of our 9-1-1 calls to which our firefighters, paramedics and EMTs respond are not life-threatening emergencies and don’t necessarily warrant ambulance transport to an emergency department.”
Now including physicians’ assistants further upgrades the program, Terrazas said.
“We changed the name [from Nurse Practitioner Response Unit] to the APRU program to incorporate either a nurse practitioner or physician’s assistant with a firefighter paramedic,” the chief said. “Our commitment … is the unit will be placed in the ‘catchment’ of the hospital that is paying for it. That way they get a direct benefit in terms of a reduction of emergency room patients. So each unit has been strategically placed to facilitate the support of the hospital.”
Dr. Ralph Baca, co-Medical Director of the Providence Tarzana Medical Center Emergency Department, said he expects to see smaller patient loads and quicker service for those needing critical help.
“The objective is to decompress the volume of patients we see in the emergency department that aren’t necessarily ‘high-acuity’ patients,” Baca said. “That’s always been a challenge for us in the hospital setting. We don’t want to turn people away; we’re there to serve everybody. But at the same time, there are a limited number of beds and limited number of resources for every hospital.
“What we’ve always struggled with is how do we provide the resources patients need with a limited capacity. A lot of that hinges on the volume of patents that come. No matter how big your ER is — whether you’re 15 beds or 50 beds — there’s always [a limit to] capacity. So how do we protect the resource we have to provide the kind of care we want? This is a real big step in that direction.”
Eckstein added that the LAFD should also be able to better track what it defines as heavy repeat users of the 9-1-1 system.
“We call them ‘EMS super users,’” he said. “There is a [sector of patients] who have created a reliance on the 9-1-1 system, who call sometimes hundreds of times per year for paramedics and firefighters to come out and help them with a myriad of issues. Some of these are chronic medical conditions, social issues, mental health issues and substance abuse.
“So a critical mission of the APRUs is to do an evaluation of the ‘super users,’ and help them navigate through the healthcare system to get the help they need, and sever their reliance on the 9-1-1 system for their day-to-day needs.”
Terrance Ito, a nurse practitioner and EMS advanced provider, and Hiram Cuahutle, a firefighter paramedic, are the two-person team that will operate the AP7 rig in Valley communities like Arleta, and Pacoima. A quick tour of their vehicle showed the customary equipment in LAFD emergency vehicles, but also a couple of key additions — a small refrigerator for transporting body fluid samples taken at accident or incident scenes, and a tool kit box filled with sutures, staples, and non-narcotic medications for pain and other treatments.
The LAFD has slowly been adding new equipment and personnel this year. Terrazas hopes the APRU program will prove valuable enough that funding for it will continue beyond one year.
“My goal is to get one of these per battalion,” he said. “By the end of this fiscal year we will be at seven. My goal for the next fiscal year is to get the other seven.”